...According to proponents, this "individual mandate" will increase the size of insurance risk pools and bring down premiums. Young and healthy people who might normally go without insurance will be forced to buy into the system and, in effect, subsidize the old and sick.

Of course, this line of reasoning ignores the fact that many Americans are uninsured not because they want to be but because they can't afford insurance. Nationwide, the average annual premium for family health coverage is $12,300. That figure is expected to double over the next decade.

Forcing millions to purchase budget-busting insurance policies or face hefty fines will push family bank accounts to the brink and make economic recovery even harder.

The Baucus plan attempts to address these affordability concerns by allocating billions in subsidies to people with incomes up to four times the poverty level, or $88,000 for a family of four. But with health insurance costs rising at astronomical rates, taxpayers will no doubt have to shell out ever-increasing amounts each year so that the subsidies can keep pace.

In more than a dozen statehouses across the country, a small but growing group of lawmakers is pressing for state constitutional amendments that would outlaw a crucial element of the health care plans under discussion in Washington: the requirement that nearly everyone buy insurance or pay a penalty.

...[T]the measures could create legal collisions that would be both expensive and cause delays to health care changes, and could be a rallying point for opponents in the increasingly tense debate.

I'm not a lawyer, so I don't know how successful these challenges will be.

But if it helps focus public attention on the underlying issue of whether the government should be able to force individuals to purchase any product (such as insurance) as a requirement for residing in this country, then I hope it spurs some debate.

If past cycles are any indicator, we are about due for another round of studies showing that being uninsured kills. Headlines will abound, commentators will wring their hands, and anyone who opposes ObamaCare will be portrayed as an insensitive killer.

The good news is that the majority of the supposed deaths due to a lack of health insurance are statistical artifacts. Unlike deaths from government health care, which has been extensively documented to cause harm to the seriously ill, the elderly, and the newborn, the deaths due to a lack of health insurance are usually conjured out of data sets using a variety of statistical tricks...

Gorman makes an important point. Too many politicians equate "coverage" (i.e., insurance) with actual medical care. But as we've seen in states like Massachusetts and Hawaii, policies that attempt to provide universal "coverage" typically decrease patients' ability to get medical care.

The mandatory insurance proposed by the President and Congress is at least partially based on the fallacy that "coverage = care". Hence, it's crucially important that analysts like Gorman are speaking out to challenge that fallacy.

...President Obama proposes to require insurers to sell policies to everyone no matter what their health status. By itself this requirement, called "guaranteed issue," would just mean that insurers would charge predictably sick people the extremely high insurance premiums that reflect their future expected costs. But if Congress adds another requirement, called "community rating," insurers' ability to charge higher premiums for higher risks will be sharply limited.

Thus a healthy 25-year-old and a 55-year-old with cancer would pay nearly the same premium for a health policy. Mr. Obama and his allies emphasize the benefits for the 55-year old. But the 25-year-old, who may also have a lower income, would pay significantly more than needed to cover his expected costs.

...But the combination of a guaranteed issue, community rating and an individual mandate means that younger, healthier, lower-income earners would be forced to subsidize older, sicker, higher-income earners. And because these subsidies are buried within health-insurance premiums, the massive income redistribution is hidden from public view and not debated.

Basically, the Obama-Baucus system of mandatory insurance forces the young and healthy to subsidize the old and ill, using the nominally private insurance system to conceal the fact that it's a new welfare program.

Most of his ideas involve repealing the bad laws that created the problem in the first place, such as the unfair tax exemption for employer-provided health insurance, as well as various insurance mandates and regulations restricting the freedom of contract between customers and insurers.

Thursday, September 24, 2009

Jared Rhoads of the Lucidicus Project cuts through the double-speak of the Obama Administration's proposed health care goals.

His essay, "Bad Goals, Bad Solutions" discusses the following goals, including the best possible free market interpretation and the actual big-government meaning:

1) "Bring down skyrocketing costs"2) "Cover all Americans"3) "Modernize our system"4) "Ensure that people aren't overcharged for prescription drugs"5) "Ensure that people aren't discriminated against for pre-existing conditions"6) "Eliminate fraud, waste, and abuse in government programs"

Now that the health care issue is front-and-center on the political radar, our web designer Tod has added four new pages to the FIRM website which include a compilation (with links) of all of the health care OpEds and articles written by myself, Ari Armstrong, Brian Schwartz, Lin Zinser, etc.

So please feel free to steer people towards the list of "All Articles/Editorials", to the subpages for Ari, Brian, and myself, or to any individual pieces.

The "All Articles" page lists the 44 OpEds and 3 health care articles published between January 1, 2007 (when Lin started FIRM) and September 23, 2009, listed in order of most recent to oldest. We have also included the revised 2007 version of Dr. Peikoff's "Health Care is Not A Right" as the top-most item in the Articles section. As we add more articles and OpEds, Dr. Peikoff's piece will always remain on top.

So to my fellow FIRM writers -- thank you for all your help and support!

Wednesday, September 23, 2009

What has been missing from the national discussion on health reform is an analysis of the dynamic consequences of significantly increasing the level of statism in the medical field.

If the United States implements H.R. 3200, the resulting conditions will not come to resemble that of any current Western medical system or bestow any of their purported advantages. The U.S. medical system will collapse, and it will take down every major medical system throughout the world with it...

Too many supporters of "universal health care" say that "medicine should be about patients, not profit".

Yet it is precisely the profit motive and the opportunity to create and trade value that drives medical innovation. As Milling notes:

The demolition of profits and a more austere and coercive environment will result in the flight of significant numbers of these people from the medical field. As the profits in the industry disappear, so will the supply of mental capital, as the best minds that would otherwise fuel the advancement of the sector will leave it for more profitable ones. It is worth noting here that the term "brain drain" was coined to describe such a loss from Great Britain after socialized medicine was instituted there in the 1950s.

This will be seen in many forms. There will be decreased interest in medical school among the best and brightest youth. There will be early retirements by experienced but frustrated doctors. The caps on prices and reimbursements will squeeze medical equipment manufacturers, who will lay off engineers and decrease their product development. Pharmaceutical and biotech companies will make cuts in research and development and lay off scientists, and their drug pipelines will become empty. Fewer smart people will choose a career in healthcare management or allied industries.

There will be no rescue of the medical system by productivity. Productivity in medicine will itself be in need of rescue.

In such a state, world medicine would be vulnerable to powerful stressors that could push it past the breaking point. That stressor would likely be the onset of a flood of end-of-life demand by the Baby Boomer demographic, at which point the system would become irreversibly overwhelmed. At current life expectancies for U.S. males, this would occur around the year 2021.

At some point, all national plans would go bankrupt, necessitating either a move toward laissez-faire, or a descent into sub-industrial medicine.

On September 11, 2009 CEI and the Ayn Rand Center for Individual Rights held an "intellectual ammunition" strategy session at the National Press Club in Washington, D.C. to brief the participating in the 9/12 March on Washington on the ideas of liberty.

This video includes the presentation "Individual Rights and the Tea Party Movement" by Prof. John D. Lewis of Duke University and questions from the audience.

...Look no further than the $40 billion "fee" that Mr. Baucus wants to impose on medical devices and diagnostic equipment. Device manufacturers would pay $4 billion a year in excise taxes, divvied up among them based on U.S. sales. This translates to an annual income tax surcharge anywhere from 10% to 30%, depending on the corporation.

... Convinced by the White House that legislation was inevitable, most of the health-care lobbies decided to negotiate and pay ransoms so Democrats would spare their industries greater harm. Sure enough, the device maker lobby, AdvaMed, was among the "stakeholders" that joined with Mr. Obama in a Rose Garden ceremony in May and pledged to "save" $2 trillion over 10 years to fund his program.

AdvaMed was nothing if not a team player. It endorsed Democratic inspirations like comparative-effectiveness research and value-based purchasing, despite the danger that under such centralized decision-making the government will decide that the most effective and valuable treatments also happen to be the cheapest—rather than those that are best for patients. It also suggested a variety of other taxes that would have resulted in a lower bottom line, much as Big Pharma promised $80 billion in drug discounts and the American Hospital Association agreed to $155 billion in Medicare and Medicaid reimbursement cuts.

But the word on Capitol Hill is that AdvaMed's tribute wasn't handsome enough for Mr. Baucus's tastes. The massive new tax—which wasn't a part of any of his policy blueprints released earlier this year—is in part retaliation.

Instead of making a principled stand against the proposed legislation, they attempted to play the special interest lobby game to try to cut the best deal for themselves.

But then they got outplayed by other lobby groups with more pull and paid the price. In other words, the politicians accepted their political cover (i.e., moral sanction), then stabbed them in the back:

Old Washington hands are saying the device lobby made a "strategic mistake" by not offering Mr. Baucus more protection money, but the real mistake was trying to buy into the ObamaCare process, instead of trying to defeat its worst ideas outright.

(Emphasis mine.)

Sometimes, when you think you're getting a "seat at the table", all it means is that you're being served for dinner...

Democrats pretend that Republicans are just a bunch of obstructionists when it comes to health proposals. Meanwhile, Republicans debate minor aspects of Barack Obama's plan such as whether it subsidizes illegal immigrants and abortions.

The reality is that every key element of Obama's plan either came from Republicans or arose with Republican support...

To the extent that Republicans are merely fighting over how much to "me-too" the Democrats, then they've already lost. And so will the country.

...The fundamental distinction Dad was making is how differently the two systems view the patient and the incentives that view creates in each. The private fee for service system has more incentives to keep its patient alive and help them get better. Under socialized systems, and Medicare/Medicaid is a socialized-lite system, the overriding incentive is to control costs because the funds are finite and the needs are not.

I don't think I need to tell you which system Dad thought was better.

Of course he thought the private system vastly superior, even though he had his issues with that too. However, most of the issues he did have with it were created by government interference in the period after Medicare was enacted. Medicare doesn’t control costs, it controls prices. The costs just get shifted to someone else. The decisions on what to pay for exams were more or less completely arbitrary. Any time Medicare was looking for "cost" savings it simply dictated them by reducing reimbursement rates or, in other words, price fixing. The costs didn't actually disappear though. They just had to be shifted to the private patients who ended up subsidizing the Medicare patients. It is in this way that healthcare has become so expensive in the private sector. We pay for our own healthcare, subsidize the Medicare/Medicaid patients and carry the full freight on the people with no insurance who show up in the ER and must, by law, be treated.

Rationing is what we will get if we go down the socialized healthcare delivery path, the dead patient as cost savings view is likely to become dominant because the government, as single payer, is going to be forced to ration. The funding available to pay for medical care will be finite yet demand for "free" services will be infinite. The government will tell us if and when we may see a doctor. It will tell us what care and what procedures we will receive. That is the only possible outcome of a complete nationalization of our medical care delivery system. True healthcare reform will only come about by reducing government involvement in delivery, not further encroachment or a complete takeover.

Friday, September 18, 2009

In a recent editorial published by Investor's Business Daily, associate editor (and PJTV.com regular) Terry Jones revealed stunning poll data showing that 45 percent of American physicians "would consider leaving their practice or taking an early retirement" if Congress passed the proposed ObamaCare health legislation.

As a practicing physician, I'm not surprised. These numbers mirror the sentiments I’ve heard expressed by my professional colleagues. I've been in practice for over 15 years and I've never seen physician morale as low as it is today.

Older physicians have told me that they're glad to be "getting out" and retiring soon. Medical students have asked me whether they should switch to engineering or pharmacology before it's too late. Physicians in the middle of their careers are just hoping to survive any "reform."

The same IBD poll also showed that an overwhelming majority (65 percent) of physicians were opposed to the proposed expansion of government in medicine. And they have every reason to be concerned, based on past experience...

I've seen some people disputing the methodology of the IBD survey, citing other surveys stating that physicians support ObamaCare. I haven't looked at those other surveys (yet), so I can't comment on their specific claims.

But the broader point raised by the IBD survey is fundamentally correct -- doctors are concerned that the proposed "reform" will make their jobs and their lives more difficult. I don't know exactly how many of my colleagues will retire early or quit in frustration. But it's definitely a topic of conversation when physicians are talking amongst themselves away from their patients.

1. If we know we can buy health insurance after we get sick with no increase in premiums, none of us will want to pay premiums for insurance while we are healthy. Yet, if only the sick are paying premiums, the entire insurance system will collapse.

2. So to prevent collapse, there must be a requirement that people buy in when they are healthy.

3. Now if the requirement is a general mandate -- with lots of coverage options -- we are back to a variation of the problem in 1. People will choose scaled down, inexpensive insurance when they are healthy and then switch to comprehensive, expensive insurance after they get sick.

4. So to prevent a meltdown similar to the one described in 1, choices must be eliminated and there must be a standard (government-defined) benefit package which all individuals are required to buy and all insurers are required to sell. People won’t be allowed to buy anything less generous and no insurer would be foolish enough to offer anything more generous.

5. Now suppose there is a health insurance Exchange where people get their insurance, but insurance can also be sold outside the Exchange. In particular, imagine a special deal offered to the Iron Man's Club (requirement: swim a mile, run 10 miles and bicycle 20 miles). Soon, word would get out that anyone who can qualify for Iron Man membership can get the standard benefit package for a really cheap price. In this, and in other ways, insurers outside the Exchange would siphon away the healthiest people leaving the Exchange with the sickest, most costly enrollees.

6. So to prevent the death spiral the conditions in 5 would lead to, insurance outside the Exchange would have to be outlawed and insurance within the Exchange highly regulated. (See below.)

7. How can you force people to buy insurance? Since cattle prods are too impractical and prison cells are too expensive, about the only practical tool is a fine. And if you want it to work, the fine needs to be near (and maybe even above) the premium people have to pay.

8. Of course, there is this problem: How can we know whether anyone has insurance? The easiest way -- without a new bureaucracy -- is to rely on the income tax system. Make people show proof of insurance at the time they file their income taxes.

9. Trouble is: People file tax returns once a year and most people who are currently uninsured are uninsured for less than a year. So a logical way to get to people with greater regularity is to use the employers as an enforcement mechanism.

10. Once employers are involved, however, we run into the unfortunate fact that most people believe that premium payments are an addition to wages, not a substitute for them. So to the question, "should we mandate that you buy insurance or that your employer buy it for you," the employer tends to win hands down. Result: both an individual mandate and an employer mandate seem inevitable.

Notice the cyclical pattern in all of this. You distort incentives in a complex system and you get perverse behavior. To prevent that, you distort incentives some more and you get other kinds of perverse behavior. The more you intervene, the greater the need for even more intervention.

One of the methods used by statists to destroy capitalism consists in establishing controls that tie a given industry hand and foot, making it unable to solve its problems, then declaring that freedom has failed and stronger controls are necessary.

Too often, the high cost of health care is blamed on the cost of technology. But in other sectors of the economy (cell phones, computers, DVD players), technology keeps getting cheaper and better with the time. It's only because of government interference in the health care marketplace that we see the current perverse trend of rising costs.

The fundamental issue is not profit versus nonprofit, but freedom versus force. The problem with insurance companies is not that they seek to make a profit, but that they must operate as de facto agents of political overseers who call the shots.

On a truly free market, in which insurers and their customers were free from today's political controls, people would tend to buy insurance directly, rather than get stuck with the few non-portable plans their employer chooses for them.

In a free market, insurers would be free to offer more plans to more people, and consumers would be free to shop around, regardless of state boundaries. Politicians would no longer coddle insurers with protectionist controls and tax favoritism.

In a free market, insurers would compete on the basis of quality, security, and transparency of contract. Today, because of political controls, insurance companies face little real competition, and they would face even less under Obama's policies.

In a free market, insurance companies would be able to offer long-term policies that today are politically impossible.

Wednesday, September 16, 2009

Terry Jones' OpEd in the September 15, 2009 edition of Investor's Business Daily discusses some interesting poll data on doctors' opinion of ObamaCare. Here are a couple of highlights:

• Two-thirds, or 65%, of doctors say they oppose the proposed government expansion plan. This contradicts the administration's claims that doctors are part of an "unprecedented coalition" supporting a medical overhaul.

• Four of nine doctors, or 45%, said they "would consider leaving their practice or taking an early retirement" if Congress passes the plan the Democratic majority and White House have in mind.

More than 800,000 doctors were practicing in 2006, the government says. Projecting the poll's finding onto that population, 360,000 doctors would consider quitting...

In Ayn Rand's classic novel Atlas Shrugged, one of the characters is physician Thomas Hendricks who made that choice:

..."I quit when medicine was placed under State control some years ago," said Dr. Hendricks. "Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill? That was what I could not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes at the point of a gun. I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward.

"I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything -- except the desires of the doctors. Men considered only the 'welfare' of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, but 'to serve.' That a man's willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards -- never occurred to those who proposed to help the sick by making life impossible for the healthy.

"I have often wondered at the smugness at which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind -- yet what is it they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn.

"Let them discover the kind of doctors that their system will now produce. Let them discover, in the operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man they have throttled. It is not safe, if he is the sort of man who resents it -- and still less safe, if he is the sort who doesn't."

Tuesday, September 15, 2009

The battle over health care is a battle over ideas -- namely what is the proper relationship of the government to the individual.

Brian Phillips tackles this issue head on in his recent blog post, "Political Magic". Here's an excerpt:

...Certainly, some people suffer misfortune through no fault of their own. Such situations are tragic, and I do not mean to diminish the impact on the lives of those involved. But one person's tragedy, no matter how dire, does not provide him with a claim on the lives and property of others. One person's need does not give him a right to steal from others, and this doesn't change merely because government acts as his proxy.

...Ms. Bennett and her ilk do not realize that they are chewing off the hand that feeds them. They don't concern themselves with tomorrow, because they count on another hand to magically appear. And unfortunately, there is an abundance of politicians who think that they are magicians.

Unless our politicians (and more importantly, Americans) shed this type of "magical thinking" about where goods and services come from, they'll just assume they can pass laws guaranteeing them from "somewhere".

Of course, reality will teach us a lesson. The only question is whether we'll be learning that lesson sooner or later.

The issue of whether President Obama supports a public option is a red herring. The proposed health care reforms, even without a public option, will devastate the quality of health care in the U.S.

President Obama has portrayed a false alternative: more government involvement or no reform at all. Yet there are other options.

The only reforms that will address the actual problems with our health system are removal of the government mandates and tax distortions, which are the cause of the rising cost of health care.

The only way to control costs is to restore the free market in health care. This is imperative both between consumers and providers as well as between consumers and insurance companies.

The government should take a cue from doctors and adopt the creed "First, do no harm." Increased government involvement in health care would be extraordinarily harmful to the well-being of all Americans.

...Obama's plan to force insurance companies to cover people with preexisting conditions combined with his plan to force everyone to buy health insurance whether he or she wants it or not would impose an implicit tax on all policyholders in the form of insurance premiums that are higher than they would have been without the program. (Some would have opted out of insurance and paid nothing.) The rich would not be the only ones taxed, no matter what Obama says.

Implicit taxes are worse than open ones because people are unaware they are paying them. Therefore they would not know how much Obama's scheme truly costs. In a supposedly free and democratic society, that is just wrong. We should at least know how much government costs.

By relabeling welfare "insurance" and claiming that only the rich will pay for his plan, Obama misleads the American people when he talks about healthcare. This is strange coming from someone who insists on honesty from his opponents.

Bad tax laws have turned health insurance from genuine insurance to bad pre-paid health care. Patients are insulated from the true costs of their medical expenses and thus have an incentive to overconsume. Insurers ignore their patients' desires because their real customers are the employers, not the employees. The result is skyrocketing costs.

As Berry notes:

...This tax preference – enjoyed primarily by employees of large businesses and government at the expense of small businesses and the uninsured – promotes the purchase of low co-pay, low deductible health insurance so that most Americans do not feel the true cost of the decisions they make about their routine, outpatient care. This elicits a trickle of expensive individual responses that collectively swell into a cascade of costly decisions for the nation as a whole.

If this tax-favored majority had to pay full price for non-catastrophic and non-emergency care, they would become more economical in their decisions without any loss in quality. They would question health care professionals about the value and cost of tests and treatments and forego the ones they judge to be of marginal value. For example, if patients with back pain had to pay for their $1,000 MRI’s, more would make the effort to learn that this test rarely affects treatment and is usually unnecessary. Loud snorers who are sleepy during the day would use an inexpensive, in-home screening test or a trial of CPAP before undergoing expensive studies in a sleep lab. For heartburn, patients would try generic Zantac at $4 per month before buying Nexium or Prevacid for $120.

... It is obvious from this month's townhall meetings that most Americans do not want a government takeover. However, simply rejecting Obamacare will not solve our health care financing problem. We can check these soaring costs by changing the tax code so as to promote direct payment for non-catastrophic care. Or we can choose to pay federal bureaucrats to cut costs for us by rationing this care in a single payer system.

In other words, to avoid getting trampled by the rhinos we must first get rid of the elephant – the tax preference for employer-based health insurance.

...[C]ontrary to proposals being put forth by Republicans, a genuinely free market in health insurance is not only moral, in that it respects the rights of producers and consumers, but also practical, in that it enables businessmen to solve problems for profit -- which leads to more and better products and services at lower prices for consumers.

...The protests and the polls are clear: Americans have, by and large, rejected the radical leftist agenda. But the issue is not yet closed. The Democrats have one last resource -- one secret weapon -- with which they can save their plans while avoiding political suicide in the next election. That weapon is the Republicans.

If the Republicans compromise -- if they accept federally-mandated health insurance in the guise of a "co-op" or the like, or a cap-and-trade bill that is marginally less draconian than the Democratic version -- they will have once again capitulated to their opponents, abandoned liberty, and ruined the opportunity to redirect this nation toward its founding moral principle: individual rights, protected under a constitution in a free republic.

As a result of the current political crisis, Craig has graciously chosen to make my article available for free to subscribers and non-subscribers alike.

So if you are inclined, please feel free to forward the article link to friends, family, colleagues, and/or elected officials:

Thursday, September 10, 2009

...It never ceases to amaze when politicians who demagogue against "greedy" insurance companies will, in their next breath, require us to buy things through an insurance company that we could purchase less expensively if we simply paid out of pocket.

If both you and your doctor know that you need a colonoscopy, how can it possibly be cheaper for you to send your payment to an insurance company, while the doctor files a claim with that insurance company, and the insurance company processes the claim and issues payment -- rather than for you to simply pay the doctor?

Yet ObamaCare would establish a mandatory list of insurable procedures as well as maximum deductibles. For those with money-saving high-deductible plans and health savings accounts — like the one I've had for 12 years -- the President’s promise that we can keep the plan we have just doesn't wash.

Americans who are understandably frustrated by health care costs are recognizing that the more control you give to government the more control you give to government.

Today, if you, your doctor and your insurer agree on a procedure, you make an appointment and "get 'er done." And if you can't agree, you are free to pursue other procedures that you can pay for yourself. (After all, what good is an extra $50,000 in your retirement account if you're dead?)

But if no one practices those alternative procedures because omnipotent health care bureaucrats won't pay for them, you are out of luck.

The larger point is this: Why is it government's business how much you pay, what doctor you see, or what treatment you receive, so long as you are paying the bill?

Hillman also makes the (too often) underappreciated point that health care is a commodity, subject to all the usual real-world laws of economics:

If the government is empowered to supervise everyone's health care, then only two outcomes are possible: either everyone's health care is rationed to control costs or no one's health care is rationed and the cost of government health care finally breaks the camel's back, ushering in a worthless dollar, runaway inflation and skyrocketing interest rates.

...There can be no health care utopia any more than everyone can enjoy all they want to eat or live in the home of their dreams. Sooner or later, someone must choose between what we want and what we can afford.

Who do you want to make those tough choices -- yourself or someone in government?

Hillman is asking the questions that all of us should be asking ourselves.

A popular but flawed argument is that "health care is a right, not a privilege." Health care is neither a right nor a privilege. Rather, we all have the right to seek medical treatment through voluntary trade or charity.

Ironically, those who claim health care is "a right and not a privilege" support policies that make it a privilege. When government enforces an alleged "right" to health care, the political class decides what health care is and when it's appropriate for people to get it. That is, health care becomes a privilege granted by those in charge.

For example, Canadian authorities deemed Bill Murray of Alberta “too old” for a hip procedure -- and prohibited him from paying for it himself...

...Rights that Americans would lose under proposed reforms include: the right to buy true insurance, for which premiums are based on risk; the right to decline to buy a plan they don't want; the right to self insure; the right to reap the benefits of healthful living, hard work, and prudent spending; and the right to keep their medical records confidential. If the reforms evolve into a single payer, as many advocates intend, Americans would lose the liberty to use their own property to prolong or enhance their own lives.

Obligations that reform would impose on Americans include: continually proving that they had paid for coverage that the federal government deems acceptable; paying what the government deems to be their "fair share" for insuring persons below a certain income threshold; paying for procedures they deem to be harmful or immoral if coverage is mandated by government; and paying for expanded, costly bureaucracy.

America's extraordinary prosperity and technological progress occurred in an atmosphere of freedom. The losses resulting from a central chokehold on innovation are incalculable. Advocates of reform often attribute the high cost of American medicine to new drugs, devices, and procedures, and want still-heavier regulation to restrain these advances. Both Americans and the result of the world's peoples will lose if America is no longer the engine of progress.

Americans are being asked to exchange their birthright of freedom for -- politicians' promises. And to trade their natural, God-given rights to life, liberty, and property for government-granted privileges or entitlements.

Overall, their points are good. Americans must challenge the idea that ObamaCare is synonymous with "reform". Socialism is not "reform". And adopting the failed health care policies of Canada and Europe is not "change".

I do have one small quibble about their use of the term "God-given rights". Properly understood, tights are not something granted to man by God; instead, they are objective requirements necessary for humans to survive in a social context.

The source of man's rights is not divine law or congressional law, but the law of identity. A is A -- and Man is Man. Rights are conditions of existence required by man’s nature for his proper survival. If man is to live on earth, it is right for him to use his mind, it is right to act on his own free judgment, it is right to work for his values and to keep the product of his work. If life on earth is his purpose, he has a right to live as a rational being: nature forbids him the irrational.

Monday, September 7, 2009

[This post isn't on health care policy, but rather personal health care. Feel free to forward it to anyone else who might be interested. -- PSH]

Last week I attended a medical conference which included an update on the radiology of skeletal and orthopedic disease.

Although most of the lectures were intended for health professionals, there was one lecture which included information that would be of interest to the general public because it involved the common condition known as osteoporosis.

After women undergo menopause, many of them start losing bone mineral at a significant rate -- enough that they are at increased risk of developing fractures of the hip, spine, and other bones from relatively minor trauma. This condition of abnormal low bone density is known as "osteoporosis". In particular, hip fractures can be devastating to older women, and can often result in permanent disability or premature death.

In the past, women with osteoporosis (but who had not yet developed a fracture) were often treated with hormone replacement therapy in order to reduce their risk of these fractures. (Hormone replacement therapy was also widely used to alleviate the uncomfortable "hot flashes" associated with menopause). But because recent research has shown that these hormones can also increase the risks of certain cancers of the female reproductive system, this is no longer commonly done.

Instead, starting 4-5 years ago, many primary care physicians started treating such women with a different set of drugs designed to help protect and restore bone mineral density. One commonly prescribed family of drugs is known as bisphosphonates, and some examples include Fosamax, Boniva, and Actonel. These drugs have proven effective in halting (or even reversing) the mineral loss, and have also reduced the risk of these potentially devastating hip fractures.

However, in recent years there have been reports that these drugs can also paradoxically increase the risk of a certain type of upper thigh fracture (known as "subtrochanteric proximal femur fractures"). Although physicians and scientists don't fully understand the cause, it appears that women who have been on these drugs for a few years start developing tiny stress fractures in the upper femur bone (below the level of the hip joint), which gradually increase in size. Eventually, a certain percentage of these turn into complete fractures, and often the triggering event might be a relatively minor fall or bump.

This has only been recognized in the past year or so, as more women reach the point where they've been on these drugs for the (apparent) requisite time of 4-5 years.

So if you are a post-menopausal woman who has been diagnosed with either "low bone density" or "osteoporosis", and you are currently taking one of these drugs, then you need to be on the lookout for any new pain in the upper thigh region. This could be an early warning sign of a developing stress fracture.

Here is an example of an early stress fracture in the right femur (thigh) bone:

Your physician can then order various radiology tests (x-ray, MRI, or nuclear medicine bone scan) to see if you are developing a stress fracture. These can often affect both sides, even if you only feel the pain on one side. If you have one of these fractures, then your doctor can recommend the appropriate treatment.

For the time being, the benefits of these drugs are still felt to outweigh the potential drawbacks. Hence, physicians are not currently recommending that women who are taking them should discontinue them. And a lot more effort is being focused on this problem, now that doctors and scientists have become aware of it. The exact guidelines as to who should (or should not) be on these medications will undoubtedly undergo refinement as the research develops. As usual, if you have specific concerns, you should discuss them with their own personal physician.

Summary:

If you are taking a bisphosphonate drug such as Fosamax, Actonel, or Boniva, and you start experiencing upper thigh pain, get it checked out immediately. It could be an early stress fracture, which needs to be detected and treated before it becomes a complete fracture. This is especially important for women who are athletically active (e.g., running, tennis, etc.)

Even if you personally don't take these drugs, it's very likely you will know someone in your family or circle of friends who does.

(Obligatory disclaimer for any lawyers out there: This should not be construed as personal medical advice. If you have any questions about your specific situation, please consult your personal physician.)

Nearly a century ago, the Federal Reserve Board was created to eliminate the supposed economic problems of a free market. A century of inflation, recessions, one or two depressions, huge expansion in government debt, and wild swings in unemployment tells us the system may not be working.

Now, after forty years of expansive spending by Medicare and Medicaid -- uncontrolled and without funding -- we are told that what we need is the creation of Fannie Med to take over what remains of private health care. People are starting to get suspicious...

* Legal "DRGs." Each potential legal situation will be assigned a relative value, and charges limited to this amount. Program participation and acceptance of this amount is mandatory, regardless of the number of hours spent on the matter. Government schedules of flat fees for each service, analogous to medicine's Diagnosis Related Groups (DRGs), will be issued. For example, any divorce will have a set fee of, say, $1,000, regardless of its simplicity or complexity. This will eliminate shady hourly billing. Niggling fees such as $2 per page photocopied or faxed would disappear. Who else nickels-and-dimes you while at the same time charging hundreds of dollars per hour? I'm surprised lawyers don't tack shipping and handling onto their bills.

* Ration legal care. One may need to wait months to consult an attorney. Despite a perceived legal need, physician review panels or government bureaucrats may deem advice unnecessary. Possibly one may not get representation before court dates or deadlines. But that' s tough: What do you want for "free"?

* Discourage/eliminate specialization. Legal specialists with extra training and experience charge more money, contributing to increased costs of legal care, making it unaffordable for many. This reform will guarantee a selection of mediocre, unmotivated attorneys but should help slow rising legal costs. Big shot under indictment? Classified National Archives documents down your pants? Sitting president defending against impeachment? Have FBI agents found $90,000 in your freezer? Too bad. Under reform you too may have to go to the government legal shop for advice.

* Collect data about the supply of and demand for attorneys. Create a commission to study the diversity and geographic distribution of attorneys, with power to stipulate and enforce corrective actions to right imbalances. The more bureaucracy the better. One can never have too many eyes watching these sleazy sneaks.

The Massachusetts Legislature is considering more than 70 additional requirements.

...As goes choice, so goes quality. Statistics on waiting times for specialist care in Massachusetts read like a dispatch from Canada. In 2004, Boston already had the longest waits among metropolitan areas. By 2009, waits had generally shortened in other metro areas (average wait: less than three weeks) but lengthened in Boston (average wait: seven weeks), according to the Merritt Hawkins survey.

...Nevertheless, those costs are appearing in higher taxes and health insurance premiums. State officials have raised taxes on tobacco, hospitals, insurers and employers, as well as eliminated coverage for many legal immigrants just to scrape up their 20 percent share of the cost. They are also showing the nation where ObamaCare would ultimately lead: government-imposed rationing.

To cope with the cost of its reforms, Massachusetts created a legislative commission that has recommended moving the entire market to a single, Canadian-style payment system that would encourage doctors and hospitals to ration care.

Thursday, September 3, 2009

...Under the various proposals now on the table, the IRS would become the main agency for determining who has an "acceptable" health insurance plan; for finding and punishing those who don't have such a plan; for subsidizing individual health insurance costs through the issuance of a tax credits; and for enforcing the rules on those who attempt to opt out, abuse, or game the system. A substantial portion of H.R. 3200, the House health care bill, is devoted to amending the Internal Revenue Code of 1986 in order to give the IRS the authority to perform these new duties.

The Democrats' plan would require all Americans to have "acceptable" insurance coverage (the legislation includes long and complex definitions of "acceptable") and would designate the IRS as the agency charged with enforcing that requirement. On your yearly 1040 tax return, you would be required to attest that you have "acceptable" coverage. Of course, you might be lying, or simply confused about whether or not you are covered, so the IRS would need a way to check your claim for accuracy. Under current plans, insurers would be required to submit to the IRS something like the 1099 form in which taxpayers report outside income. The IRS would then check the information it receives from the insurers against what you have submitted on your tax form.

If it all matches up, you're fine. If it doesn't, you will hear from the IRS. And if you don't have "acceptable" coverage, you will be subject to substantial fines — fines that will be administered by the IRS.

Under some versions of health reform now circulating on Capitol Hill, the IRS would also be intimately involved in how you pay for insurance. Everyone would be required to buy coverage. The millions of Americans who can't afford it would receive a subsidy to pay for it. Under the version of the plan currently under negotiation in the Senate Finance Committee, that subsidy would come through the IRS in the form of a refundable tax credit. Under the House plan, the subsidy would come directly from the Health Choices Administration.

In either scenario, the IRS would be the key to making the system work.

In other words, health care "reform" would mean massive new intrusions into Americans' personal and financial lives.

Government promises of "universal" health care are anything but free. Instead, we'll all pay a massive price in the form of loss of personal freedom. Nor can the government actually guarantee health care. The only thing they can guarantee is rationing and waiting lists, as we've already seen in Canada, the UK, and Massachusetts.

Our friend Hannah Krening recently sent this message to her federal representative Mike Coffman and GOP Chairman Michael Steele (in response to this PJTV interview, I think). Diana and I really like it, so I'm posting it with her permission. She writes:

As a taxpayer, breast cancer survivor and one whose first husband lost a long battle with cancer, I want to say that the current proposed "reform" of health care adds up to one thing for me: I hope I never have a life-threatening condition again if any proposal to further involve government in my health care becomes reality. And I hope that nobody I love has to be subjected to the rationing, waiting and other debilitating results of what they evidently believe are the best of intentions.

I know you are against HR 3200. But I fear you may compromise on some important principles as you fight against it. Please hear me out.

Bringing more government involvement into health care "reform" is not a solution. It is a recipe for disaster. Only by reducing government involvement in health care will we get the kind of justice that will bring about the best care for all at the best possible price.

Republicans who hint at "tweaking" the current ideas or "slowing down" their implementation are no better; the premise of government involvement and what the current web of regulations and mandates has already caused is the issue we must all face now to prevent untold and unnecessary suffering down the road. So above all, PLEASE do not be one of the many Republicans willing to compromise principles with those who profit by your abdication of them!

We must remember that health care is not and cannot be free: the skills of doctors, researchers and technology companies must be fairly compensated. The alternative is slavery: of the few taxpayers who will foot the huge bills and of the competent providers of health care goods and services, who will ultimately leave the field in order not to be enslaved by it.

Another area that needs to be understood better is the concept of insurance, which is properly for catastrophe, spreading out the risk of situations that would ruin us financially. The history and cause of the current state of health insurance has root causes that include (surprise!) government taxation laws and regulations. HSAs and high deductible insurance will be the first to disappear if the "reformers" get their way.

As you consider your input on Republican policy, I hope you will avail yourself of some excellent information on the principles needed to fight the current proposals for the best results, go to http://www.WeStandFirm.org. In addition, people like John Mackey of Whole Foods have started to offer real solutions, not just criticisms of HR 3200. These ideas need to be a part of the discussion.

This is not regulation on some dispensable part of our lives. This concerns everyone's survival, to some degree; nobody will be untouched by the outcome of this process. We have a lot to lose.

Tuesday, September 1, 2009

As the health care debate rages, many conservatives have correctly argued that government-run "universal care" will lead to medical rationing. To control costs, the socialized health systems of Canada and Great Britain routinely restrict patients' access to expensive services. A Canadian with a possible brain tumor might wait months for his government-approved MRI scan, whereas an American can receive one within days.

Liberals will typically counter that a free market is just "another form of rationing" -- but by price rather than government decree. It is unjust, they say, that patients with money (or good insurance) can receive MRI scans whereas those without money cannot. Hence, they contend, the government must intervene to guarantee a supposedly fair distribution of medical services.

Too often, conservatives then concede this moral high ground to the liberals and defend the free market on purely economic grounds -- e.g., a free market would lower costs for everyone. This is a serious mistake. Supporters of the free market should not allow opponents to characterize the marketplace as a form of rationing, let alone an unjust one. Instead, supporters should defend the free market as morally just because it respects individual rights...

Some commentors have stated that this argument of rationing is just "linguistic". I disagree, and in fact that's the key point of my piece.

It's similar to the fallacy some people commit when they claim that newspapers choosing to publish some pieces and not others is "just another form of censorship". That's completely wrong. Their uncoerced choice to publish one piece over another is the exercise of the right to free speech. In contrast, it would be censorship if the government told the newspaper which pieces they could not publish (or were required to publish).

Similarly, it's a serious category error to equate uncoerced exchanges in a free market with rationing. Rationing inherently involves compulsion, which is the exact opposite of the free market. The market is how we exercise our rights, and rationing is wrong precisely because violates those rights. (Thanks to Tom Stone for this analogy.)

I'd like to thank Craig Biddle for his comments on an earlier version of this piece. Diana, Ari Armstrong and I have also had several discussions on this subject, and Ari has written a series of blog posts on this topic.

To go straight to the chapter and verse: under Section 59(B)(a) of HR3200, the bill making its way through the House, and Section 151 of the bill that passed out of a Senate committee, every American would be required to buy health insurance.

And not just any insurance: to qualify, a plan would have to meet certain government-defined standards. For example, under Section 122(b) of the House bill, all plans must cover hospitalization; outpatient hospital and clinic services; services by physicians and other health professionals, as well as supplies and equipment incidental to their services; prescription drugs, rehabilitation services, mental health and substance-abuse treatment; preventive services (to be determined by the Centers for Disease Control and Prevention and the United States Preventive Services Task Force); and maternity, well-baby, and well-child care, as well as dental, vision, and hearing services for children under age 21.

But that's not all. Section 1239(b) of the bill also establishes a federal Health Benefits Advisory Committee, headed by the U.S. surgeon general, which will have the power to develop additional minimum benefit requirements. There is no limit to how extensive those future required benefits may be.

If your current health insurance doesn't meet all those requirements, you won't be immediately forced to drop your current insurance for a government-specified plan. But you would be required to switch if you lose your current insurance or “if significant changes are made to the existing health insurance plan.”

More critically, for the 70 percent of us who get our insurance through work, those plans would all have to satisfy the government's benefit requirements within five years.

More likely, your employer will simply find that the increased cost and administrative burden is not worth it, and will dump you into the government-run "public option."

Tanner also describes more ways in which government policies would destroy current insurance plans, concluding:

Any way you look at it, under the bills currently before Congress, millions of Americans will be forced out of their current health insurance plan, even if they are happy with it. Period.

The government doesn't want you to decide what kind of insurance you can have. Instead, they'll decide for you.

About FIRM

America was founded on the principles of freedom and individual rights. Applied to medicine, the law must respect the individual rights of doctors and other providers, allowing them the freedom to practice medicine. This includes the right to choose their patients, to determine the best treatment for their patients, and to bill their patients accordingly. In the same manner, the law must respect the individual rights of patients, allowing them the freedom to seek out the best doctors and treatment they can afford.

Freedom and Individual Rights in Medicine (FIRM) promotes the philosophy of individual rights, personal responsibility, and free market economics in health care. FIRM holds that the only moral and practical way to obtain medical care is that of individuals choosing and paying for their own medical care in a capitalist free market. Federal and state regulations and entitlements, we maintain, are the two most important factors in driving up medical costs. They have created the crisis we face today.

Freedom and Individual Rights in Medicine was founded by Lin Zinser and Paul Hsieh, MD in 2007. It is now managed by Paul Hsieh, MD.